The Diabetes Attitudes, Wishes, and Needs (DAWN) Study

STUDY

. Results reported in multiple published
articles in 2005 and 2006.

SUMMARY AND COMMENTARY

Although data about the benefits of near-normal glucose control are widely
accepted, and therapies for diabetes care are more efficacious and accessible
than ever before, outcomes remain less than optimal. Data from a recent update
of the National Health and Nutrition Examination
Survey1 indicate
that only 42% of adults have hemoglobin A1c (A1C) values < 7%,
and one in five still have A1C levels ≥ 9%. Clearly, factors other than
knowledge and effective therapies affect the behaviors of patients and health
professionals and influence their ability to make optimal use of available
treatments.

The DAWN study was a cross-sectional international survey initiated in 2001
by Novo Nordisk in collaboration with the International Diabetes Federation.
The purpose of the survey was to identify a broad set of attitudes, wishes,
and needs among both people with diabetes and care providers to lay a
foundation for efforts to improve diabetes care nationally and
internationally.2

To conduct the study, researchers carried out structured interviews in
person or by telephone in 11 regions representing 13 countries, including the
United States Survey participants included 250 randomly selected generalist
and specialist physicians per region (n = 2,705), 100 randomly
selected generalist and specialist nurses per region (n = 1,122), and
250 randomly selected patients with self-reported type 1 diabetes per country
and 250 patients with self-reported type 2 diabetes (n =
5,104).2 The study
assessed several factors related to quality of diabetes care: levels of
diabetes self-management and psychological distress among people with
diabetes, quality of relationships between people with diabetes and their care
providers, collaboration among diabetes care providers, and barriers to
effective medication
therapy.3

Findings

The results of the DAWN study have been reported in multiple
articles.3-7
This review summarizes key findings from those publications.

Self-management behaviors

Reported rates of self-management behaviors were low, especially for diet
and
exercise.3,4
Only 19.4% of participants with type 1 diabetes and 16.2% with type 2 diabetes
reported that they completely carried out all of the recommendations they had
been given. Providers rated patient behaviors substantially worse, with only
7.3% estimating that their typical type 1 patient was completely adherent, and
even fewer (2.9%) estimating that their typical type 2 patient completely
followed their
recommendations.3

Diabetes-related distress

Diabetes distress was common, and providers generally recognized that
patients were concerned and that these issues interfered with their
self-management
efforts.3,4
A large majority of the patient participants (85.2%) reported a high level of
distress at the time of diagnosis, including feelings of shock, guilt, anger,
anxiety, depression, and helplessness. Many years after diagnosis (mean
duration almost 15 years), problems of living with diabetes remained common,
including fear of complications and immediate social and psychological burdens
of caring for
diabetes.3 Forty-one
percent of patients had poor well-being; however, only 10% reported receiving
psychological
treatment.4

Nurses perceived a significantly higher prevalence and severity of
psychosocial problems and used psychological strategies more frequently than
did physicians, although they rated their skills
lower.5 Both groups
used these strategies more often when they believed more patients had
psychosocial problems and that these problems affected glycemic control.
Nurses were more likely than physicians to believe that psychosocial issues
affected self-management. In comparison with other countries, U.S. providers
provided more psychosocial care themselves but were less likely to refer
patients to mental health
specialists.5

Quality of relationships between providers and patients

A large majority of patients (88.8%) rated the quality of their
relationships with their providers as good. Most providers, however, reported
that they needed a better understanding of the psychosocial consequences of
diabetes (69.8%) and the various ethnic cultures with whom they work
(78.8%).3 Better
patient-provider collaboration was associated with more favorable ratings on
all outcomes.6
Patients with fewer resources and more complications reported less access to
care and lower collaboration with their
providers.7

Provider collaboration

Team care was less than optimal, with most patients seeing fewer than two
other providers, including a primary care provider or diabetes specialist
physician, diabetes nurse, dietitian, eye doctor, foot doctor, or behavioral
specialist. Team care was rated significantly higher among patients with type
1 diabetes than among those with type 2
diabetes.5 Patients
who had a nurse available at their provider's office reported better
self-management
behaviors.7 Only
half of the patients felt that their providers talked with each other about
their care.3

Providers rated their chronic care systems and payment for diabetes care as
mediocre.7 The
United States received the lowest rating for the quality of the chronic care
health system. Patients reported that access to care was high, but not without
financial barriers.

Barriers to the effective use of medication therapy

Patients and providers identified several barriers to use of medications.
Patients using medications reported that their treatment is too complicated,
and more than one-third said they were tired of taking their medications.
Interestingly, patients rated the efficacy of insulin therapy as
low,8 with only
26.9% of those not taking insulin reporting that insulin would help them to
manage their diabetes
better.3 Self-blame
was also common among patients but was significantly lower among those who
reported better diet and exercise self-management and less diabetes-related
distress.

Of providers, 43.4% preferred to delay initiation of medications until
absolutely
necessary,3 but
specialists and opinion leaders were less likely than nurses and general
practitioners to delay
insulin.8 Delays in
initiating oral medications and insulin were strongly linked. The potential
initiation of insulin as a threat to encourage diet and exercise behaviors was
also common among health care providers, particularly in the United
States.8

Implications

As a result of the DAWN study, the second International DAWN Summit was
held in London in 2003 to initiate concrete actions. Five goals and strategies
of DAWN were identified at this
meeting:3

Promote active self-management.

Enhance psychological care.

Enhance communication between people with diabetes and health care
providers.

The DAWN study confirmed what many health care professionals and people
with diabetes have known intuitively for years: that diabetes causes multiple
psychosocial problems, that these issues are barriers to achieving adequate
glycemic control and interfere with self-management behaviors, and that our
current health care systems are poorly equipped to handle and support chronic
illness care. Although this evidence is useful, it is imperative that these
issues be addressed, both individually and collectively, by health care
professionals, patients, policy makers, and payers if diabetes care is ever to
reach the potential that the therapies and technologies make possible.

Footnotes

Martha M. Funnell, MS, RN, CDE, is co-director of the Behavioral,
Clinical, and Health Systems Intervention Research Core at the Diabetes
Research and Training Center of the University of Michigan in Ann Arbor. She
is an associate editor of Clinical Diabetes.

Note of disclosure:Ms. Funnell has received honoraria
or consulting fees from and has served on advisory panels, including the DAWN
Advisory Panel, for Novo Nordisk, which sponsored the DAWN study.